chapter 27 cardiac

4. Cardiac catheterization In cardiac catheterization, radiopaque catheters are placed in a peripheral blood vessel and advanced into the heart as a means of measuring pressures and oxygen levels in heart chambers and visualizing heart structures and blood flow patterns. Electrocardiography involves leads placed on the patient's chest do detect how electrical signals pass through the heart. Echocardiography uses high-frequency sound waves to create a picture of the structures of the heart. Electrophysiology uses catheters within the heart to diagnose dysrhythmias.

In which procedure for cardiac diagnosis are radiopaque catheters placed in a peripheral blood vessel and advanced into the heart? 1 Echocardiography 2 Electrophysiology 3 Electrocardiography 4 Cardiac catheterization

3, 4- vomiting, bradycardia

A child with heart failure is being treated with both digoxin and captopril. Which complications are likely to be due to the use of digoxin rather than captopril? Select all that apply. 1 Fever 2 Cough 3 Vomiting 4 Bradycardia 5 Hypotension 6 Allergic reactions

2, 3, 5- furosemide, chlorothiazide, spironolactone

Which medications are diuretics used in the management of heart failure? Select all that apply. 1 Digoxin 2 Furosemide 3 Chlorothiazide 4 Potassium supplements 5 Spironolactone

3 Monitor both oral and intravenous fluid intake. The child is at risk for hypovolemia and dehydration due to blood loss in the catheterization laboratory, preprocedure nothing by mouth (NPO) status, and the diuretic action of the contrast media used during the procedure. Hence, the nurse should monitor both the oral and the intravenous fluid intake of the child. Vital signs need to be monitored every 15 minutes during the immediate postcatheterization phase. Especially, the heart rate needs to be carefully assessed for evidence of dysrhythmias and bradycardia. If the dressing is bloody, the nurse should reinforce the dressing. The pressure dressing is removed on the day after the catheterization. The affected extremity is not kept elevated. It is maintained straight for 4 to 6 hours after venous catheterization and for 6 to 8 hours after arterial catheterization to facilitate healing of the cannulated vessel.

A child has undergone a cardiac catheterization procedure. Which nursing intervention should the nurse employ during the immediate postcatheterization phase? 1 Monitor vital signs every half hour. 2 Apply a new dressing if the dressing is bloody. 3 Monitor both oral and intravenous fluid intake. 4 Keep the affected extremity raised at 45 degrees.

1. Clubbing All of these are signs of hypoxemia. However, only clubbing occurs due to chronic tissue hypoxemia and polycythemia. Cyanosis occurs even with mild hypoxemia and increases when the hypoxemia becomes severe. Diminished pulses and gasping respirations are signs of poor perfusion. They occur due to severe hypoxemia and tissue hypoxia rather than chronic tissue hypoxemia.

A nurse is assessing an infant with a suspected cardiac anomaly. Which manifestation indicates the infant has chronic tissue hypoxemia? 1 Clubbing 2 Cyanosis 3 Diminished pulses 4 Gasping respirations

2, 4, 5 Parents need to know the settings of the pacemaker to be able to detect possible problems with it. Parents should learn CPR in case it is needed during an emergency. They should ensure that the child wears a Medic-Alert device in case of an emergency. Parents and the child, if old enough, are taught to take a pulse, not a blood pressure measurement. Parents should have a paper identification card with specific pacer data in case of an emergency.

Before discharge, what teaching does the nurse give to the parents of a child who has been implanted with a pacemaker? Select all that apply. 1 Learn how to take a manual blood pressure measurement. 2 Understand the settings of the pacemaker inserted. 3 Ensure that the child has the specific pacer data. 4 Learn cardiopulmonary resuscitation (CPR). 5 Ensure proper paper ID card with specific pacer data in case of emergency

4. Problematic because children with acyanotic heart defects may experience cyanosis This classification is problematic. Children with traditionally named acyanotic defects may become cyanotic, and children with traditionally classified cyanotic defects may be pink at times. The classification does not reflect the blood flow within the heart. Cardiac defects are best described by their actual pathophysiologic processes and mechanisms. Children with cyanosis may be easily identified, but that does not aid diagnosis. Cyanosis is present when children have defects in which there is mixing of oxygenated and unoxygenated blood.

Congenital heart defects have traditionally been divided into acyanotic and cyanotic defects. What does the nurse know about this system in clinical practice? 1 Helpful because it explains the hemodynamics involved 2 Problematic because cyanosis is rarely present in children 3 Helpful because children with cyanotic defects are easily identified 4 Problematic because children with acyanotic heart defects may experience cyanosis

4. A worsening of pulmonary vascular congestion A patent ductus arteriosus (PDA) allows blood to flow from the aorta (high pressure) to the pulmonary artery (low pressure). If the PDA stays open, increased pulmonary vascular congestion may occur. Increased pulmonary vascular congestion is the primary complication; pulmonary infection may occur, but it is not the priority complication. Patent ductus arteriosus involves left-to-right shunting of blood. The decreased workload on the left side of the heart is not a priority complication of a PDA.

Surgical repair for patent ductus arteriosus (PDA) is performed to prevent which complication? 1 Pulmonary infection 2 Right-to-left shunting of blood 3 Decreased workload on the heart's left side 4 A worsening of pulmonary vascular congestion

3 Place the infant in a knee-chest position. The infant with cyanotic heart disease who has an acute episode of hypoxemia during a painful procedure is having a hypercyanotic spell. The immediate intervention is to place the infant in a knee-chest position which increases systemic vascular resistance thereby diverting more blood through the pulmonary artery. Bag-mask ventilation may be necessary if placing the patient in knee-chest position doesn't work, but the infant should receive 100% FiO2 by face mask because oxygen is a pulmonary vasodilator. If knee-chest position and bag-mask ventilation are unsuccessful, subcutaneous morphine can be administered. Intubation may be indicated if the other interventions are unsuccessful.

The infant with cyanotic disease becomes acutely hypercyanotic during an intravenous catheter insertion. Which intervention does the nurse employ first? 1 Prepare for endotracheal intubation. 2 Administer morphine subcutaneously. 3 Place the infant in a knee-chest position. 4 Provide bag-mask ventilation with 21% FiO2.

1. a diuretic Furosemide is a diuretic used to eliminate excess water and salt to prevent the accumulation of fluid associated with congestive heart failure. Furosemide is not a β-blocker. Furosemide is not a form of digitalis. Furosemide is not an ACE (angiotensin-converting enzyme) inhibitor.

The nurse explains to the parents of a child receiving furosemide that it is which type of medication? 1 A diuretic 2 A β-blocker 3 An ACE inhibitor 4 A form of digitalis Furosemide is a diuretic used to eliminate excess water and salt to prevent the accumulation of fluid associated with congestive heart failure. Furosemide is not a β-blocker. Furosemide is not a form of digitalis. Furosemide is not an ACE (angiotensin-converting enzyme) inhibitor.

3. High density lipoprotein of 38 mg/dL. In children, the normal value of high density lipoprotein (HDL) is over 45 mg/dL. A value of 38 mg/dL is considered to be low and indicates that the child is at risk of coronary artery disease (CAD). An increase in the values of total cholesterol (TC), low density lipoprotein (LDL), and non-HDL cholesterol puts the child at a risk of CAD. The normal value of TC is less than 170 mg/dL, the normal value of LDL is less than 110 mg/dL, and normal value of non-HDL cholesterol is less than 120 mg/dL.

The nurse is reviewing the laboratory results of a child with congenital heart disease. What finding indicates that the child is at risk for coronary artery disease? 1 Total cholesterol of 160 mg/dL 2 Low density lipoprotein of 96 mg/dL 3 High density lipoprotein of 38 mg/dL 4 Non-high density lipoprotein of 112 mg/dL

2, 5, 6 Hypertrophic cardiomyopathy may occur due to a mutation in the genes that encode proteins of the cardiac sarcomere. In dilated cardiomyopathy, there is ventricular dilation and a greatly reduced contractility. In hypertrophic cardiomyopathy, there is an increase in heart muscle mass without an increase in the cavity size. Restrictive cardiomyopathy is rare in children. Hypertrophic cardiomyopathy is often seen in the infants of diabetic mothers. The most common cardiomyopathy in children is dilated cardiomyopathy.

What are the differences between dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy? Select all that apply. 1 Dilated cardiomyopathy is rarely seen in the pediatric age group. 2 Hypertrophic cardiomyopathy is seen due to a mutation in the genes. 3 Restrictive cardiomyopathy is often seen in infants of diabetic mothers. 4 Restrictive cardiomyopathy is the most common cardiomyopathy in children. 5 Dilated cardiomyopathy causes greatly decreased contractility of the heart muscles. 6 Hypertrophic cardiomyopathy involves an increase in muscle mass without an increase in cavity size.

4. It can measure the oxygen saturation of blood in the chambers of the heart. Unlike an echocardiography test, cardiac catheterization provides information about the oxygen saturation of blood within the chambers of the heart and the great vessels. It is an invasive procedure, in which a radiopaque catheter is inserted through a peripheral blood vessel into the heart. Echocardiography can determine the size of the heart. Neither cardiac catheterization nor echocardiography measures the electrical activity of the heart, which is measured with the help of an electrocardiogram (ECG). Both cardiac catheterization and echocardiography can detect anomalies in the anatomical structure of the heart. Echocardiography can help detect the presence or absence of the structures of the heart and their relationship to one another. Cardiac catheterization can determine anatomical abnormalities such as septal defects or obstruction to the flow of blood.

What is the advantage of the cardiac catheterization test over the echocardiography test? 1 It can determine the size of the heart. 2 It can measure the electrical activity of the heart. 3 It can detect anomalies in the anatomical structure of the heart. 4 It can measure the oxygen saturation of blood in the chambers of the heart.

4. Tachycardia, even in sleep In a child with rheumatic fever, inflammation of the myocardium or myocarditis produces tachycardia that is out of proportion to the degree of fever, especially during rest or sleep. The presence of muffled heart sounds indicates pericardial effusion. This happens due to pericarditis, or inflammation of the pericardium of the heart. In addition, pericardial effusion may cause pericardial friction rub and the child may complain of chest pain. An apical systolic murmur is due to involvement of neither the myocardium nor the pericardium. It occurs due to mitral regurgitation and reflects valvulitis or involvement of the mitral valve.

Which clinical manifestation in a child with rheumatic fever is associated with involvement of the myocardium rather than the pericardium? 1 Muffled heart sounds 2 Complain of chest pain 3 Apical systolic murmur 4 Tachycardia, even in sleep

3. Serum potassium level The serum potassium level is the most important test to consider when preparing to administer digoxin. Hypokalemia enhances the effects of digoxin, thereby increasing the risk of digoxin toxicity. Hyperkalemia diminishes the effect of digoxin. The use of certain diuretics in heart failure patients may also cause loss of sodium, chloride, and bicarbonate ions. Although the serum levels of sodium, chloride, and bicarbonate are important during heart failure therapy, their monitoring is not essential specifically during digoxin therapy.

Which is the most important laboratory test result that must be evaluated before administering digoxin to a child with congestive heart failure? 1 Serum sodium level 2 Serum chloride level 3 Serum potassium level 4 Serum bicarbonate level

3 Due to an increase in their red blood cell count Persistent hypoxemia stimulates the formation of red blood cells. This leads to polycythemia, or an increase in the total red blood cell count. This, in turn, leads to anemia if iron is not readily available to form more hemoglobin. The blood viscosity increases, and the platelets and other coagulation factors tend to be crowded out. This increases the likelihood of postoperative bleeding. The red blood cell count increases without a corresponding increase in the plasma volume. Hence, the blood viscosity increases. The number of platelets is not increased. Platelets and other coagulation factors may not be able to reach the site of injury because of the increased blood viscosity. Hypoxia causes an increase in pulmonary vascular resistance leading to a decrease in pulmonary blood flow. However, this does not increase the likelihood of postoperative bleeding.

Why do children with persistent hypoxemia have an increased likelihood of postoperative bleeding compared to normal children? 1 Due to an increase in their plasma volume 2 Due to an increase in their number of platelets 3 Due to an increase in their red blood cell count 4 Due to an increase in their pulmonary vascular resistance

1. It is a congenital heart disease. Coarctation of the aorta is a congenital heart disease found in infants. It is characterized by an obstruction of blood flow from the left ventricle. Kawasaki disease is not a congenital heart disease. It is an acute vasculitis occurring in infants or children with normal cardiac structure. Without treatment, some children develop cardiac sequelae. It is a self-limiting disease that resolves by itself in 6 to 8 weeks.

Both coarctation of the aorta and Kawasaki disease are cardiovascular dysfunctions seen in infants. How is coarctation of the aorta different from Kawasaki disease? 1 It is a congenital heart disease. 2 It obstructs blood flow into the left ventricle. 3 It happens to children with normal cardiac structure. 4 It is a self-limiting disease of the heart with normal structure.

2, 5 2. The ECG involves the placement of leads on the skin. 5. The ECG provides information about electrolyte imbalances. An electrocardiography (ECG) test involves the placement of leads, or electrodes, on the skin. These transmit the electrical impulses generated by the heart into a recording machine. It can provide information about electrolyte imbalances and their impact on heart rate and rhythm. Both ECG and cardiac magnetic resonance imaging (MRI) are noninvasive. An ECG requires no anesthesia. Infants and young children can be made to stay still during an ECG by resting them in a parent's lap during the procedure. Children under the age of 7 often require anesthesia during an MRI test. An ECG test does not involve high-frequency sound waves. It measures the electrical activity of the heart and records it on a graph paper.

How is an electrocardiography (ECG) test different from cardiac magnetic resonance imaging (MRI)? Select all that apply. 1 The ECG is a noninvasive test. 2 The ECG involves the placement of leads on the skin. 3 The ECG often requires anesthesia in young children. 4 The ECG involves the use of high-frequency sound waves. 5 The ECG provides information about electrolyte imbalances.

3. Captopril Captopril is an angiotensin converting enzyme (ACE) inhibitor. Side effects include a cough and angioedema. The health care provider needs to discontinue captopril if these side effects are noticed. Angiotensin receptor blockers such as losartan may cause an increase in potassium levels. Atenolol is a beta blocker. Such drugs may cause fatigue, a decrease in exercise tolerance, weakness, and cold extremities. They can possibly cause impotence too. Amlodipine is a calcium channel blocker that may cause peripheral edema and constipation.

A child receiving antihypertensive therapy presents with a cough and angioedema. Which drug does the health care provider need to discontinue? 1 Losartan 2 Atenolol 3 Captopril 4 Amlodipine

4. It reduces cardiac afterload by improving contractility of the heart. Both digoxin and angiotensin converting enzyme inhibitors (ACE inhibitors) such as enalapril enhance the myocardial function in heart failure. Digoxin does this by improving the contractility of the heart. Enalapril blocks the formation of angiotensin II, which results in vasodilation. This results in a decrease in blood pressure and a decrease in pulmonary and systemic resistance. ACE inhibitors reduce the secretion of aldosterone, which reduces preload by preventing volume expansion from fluid retention.

A child with heart failure has been prescribed digoxin and enalapril. How does the action of digoxin differ from that of enalapril? 1 It reduces blood pressure due to vasodilation. 2 It reduces pulmonary and systemic vascular resistance. 3 It reduces cardiac preload by preventing volume expansion. 4 It reduces cardiac afterload by improving contractility of the heart.

4. Counting the apical rate for 1 full minute When a dysrhythmia is suspected the priority nursing responsibility is to count the apical rate for 1 full minute. The child may or may not need cardiac monitoring after the apical pulse is assessed. Assessment is the first step of the nursing process, and assessing the apical pulse is a more specific assessment for detecting a dysrhythmia than blood pressure. Administering oxygen is an intervention, and the child needs to be assessed first in this case.

A nurse caring for a child suspects a dysrhythmia. What is the nurse's first action? 1 Administering oxygen 2 Setting up cardiac monitoring 3 Assessing the child's blood pressure 4 Counting the apical rate for 1 full minute

4. The child may be at risk for cardiac tamponade. Drainage from the chest tube of more than 3 mL/kg/hr for more than 3 consecutive hours may indicate postoperative hemorrhage and a risk of cardiac tamponade. This is not a normal finding; it indicates a risk for cardiac tamponade. The finding does not suggest an infection but instead postoperative hemorrhage. The finding does not suggest a need to remove the chest tube but instead the possible development of cardiac tamponade.

A nurse caring for a child with a chest tube notes drainage from the chest tube of 4 mL/kg/hr for the past 3 hours. What does this finding suggest? 1 This is a normal finding. 2 The child may have an infection. 3 The chest tube needs to be removed. 4 The child may be at risk for cardiac tamponade.

1, 3, 4, 5 Nursing care after cardiac catheterization includes removing the pressure dressing the day after catheterization and covering the site with an adhesive bandage. It is also important to keep the site clean and dry. Administering acetaminophen or ibuprofen for pain is important. Assessing the pulses, temperature, and color of extremities are some of the most important nursing responsibilities in decreasing the risk of complications. Ambulation is not encouraged until after a period of time in which the leg is kept straight to ensure clotting and prevent complications.

A nurse is caring for a child who has just undergone cardiac catheterization. Which interventions does the nurse implement? Select all that apply. 1 Keep the site clean and dry. 2 Encourage early ambulation after the procedure. 3 Administer acetaminophen or ibuprofen to relieve the child's pain. 4 Assess pulses, temperature, and color of extremities. 5 Remove the pressure dressing the day after catheterization and cover the site with an adhesive bandage.

3. Allow 30 minutes to complete a feeding The nurse should teach the mother to give the infant about 30 minutes to complete a feeding. This is considered a reasonable feeding time. A 3-hour feeding schedule works well for most infants. Feeding every 2 hours does not provide enough rest between feeds. If the infant is fed every 4 hours, an increased volume of feeding will be needed, which many infants may not be able to tolerate. Prolonging the feeding time to 45 minutes can exhaust the infant and decrease the resting period between feeds.

A nurse is caring for a fragile infant with a serious congenital heart disease. What does the nurse teach the mother about feeding the infant? 1 Feed the infant every 2 hours. 2 Feed the infant every 4 hours. 3 Allow 30 minutes to complete a feeding. 4 Allow 45 minutes to complete a feeding.

2. Allow the infant to have uninterrupted periods of sleep

A nurse is caring for an infant with heart failure. What is the best intervention for decreasing the cardiac demand of the infant? 1 Administer the antibiotics prescribed to the infant. 2 Allow the infant to have uninterrupted periods of sleep. 3 Administer humidified supplemental oxygen to the infant. 4 Make the infant sit up in a seat or hold the infant at an angle of 45 degrees.

4 Checking the apical heart rate and holding the medication if the pulse is below 90 to 110 beats/min As a rule, the drug is not given if the pulse is below 90 to 110 beats/min in infants and young children or below 70 beats/min in older children. Never give an extra dose if one is missed, and never mix digoxin with foods or other fluids.

A nurse is preparing to administer digoxin to an infant. Which is the most appropriate action when the nurse is administering digoxin? 1 Giving an extra dose if one is missed 2 Mixing the dose with juice to disguise the taste 3 Checking the apical heart rate and holding the medication if the pulse is below 70 beats/min 4 Checking the apical heart rate and holding the medication if the pulse is below 90 to 110 beats/min

2. Record the data on the nurse's notes. Because a weaker pulse is an expected finding, the nurse should document this and continue to monitor it. The pulse distal to the catheter insertion site may be weaker for the first few hours after catheterization. Elevation is not necessary; the extremity is kept straight. It should gradually increase in strength. The insertion site is kept dry.

After a patient returns from cardiac catheterization, the nurse assesses that the pulse distal to the catheter insertion site is weaker. Which is the nurse's best action? 1 Elevate the affected extremity. 2 Record the data on the nurse's notes. 3 Notify the physician of the observation. 4 Apply warm compresses to the insertion site.

2. The affected extremity feels cool when touched. If the affected extremity feels cool when touched, arterial obstruction may be present. The health care provider must be notified immediately. A weak pulse distal to the site for the first few hours after catheterization is not a cause for concern. However, the pulse should gradually increase in strength. The child's usual diet can be resumed as soon as tolerated, beginning with sips of clear liquids and advancing as the condition allows. The child must take in enough fluids to ensure adequate hydration. Blood loss, nothing by mouth (NPO) status, and diuretic actions of dyes used during the procedure increase the risk for hypovolemia and dehydration. The child must be kept in bed, with the affected extremity maintained straight for several hours, to promote healing of the cannulated vessel.

After cardiac catheterization of a child, which assessment finding is most concerning to the nurse? 1 The pulse distal to the catheterization site is weak. Correct2 The affected extremity feels cool when touched. 3 The child has resumed oral intake with clear liquids. 4 The child is in bed with the affected extremity held straight.

4 Cross-sectional echocardiography provides a two-dimensional view of the heart. Cross-sectional echocardiography is also called 2-D echocardiography. It provides a two-dimensional view of the heart and provides information about the spatial relationship of the structures. Both cross-sectional and motion-mode echocardiography are noninvasive, painless procedures. However, both can be stressful for the child. A mild sedative may be given. However, intravenous (IV) sedation is not required. IV sedation is required in the case of transesophageal echocardiography. Both cross-sectional and motion-mode echocardiography are transthoracic procedures.

How is cross-sectional echocardiography different from motion-mode echocardiography? 1 Cross-sectional echocardiography is a noninvasive, painless procedure. 2 Cross-sectional echocardiography requires intravenous sedation of the child. 3 Cross-sectional echocardiography is a form of transthoracic echocardiography. 4 Cross-sectional echocardiography provides a two-dimensional view of the heart.

2. Echocardiography Echocardiography involves the use of high-frequency sound waves. The child undergoing this procedure must lie completely still. With improvements in technology a diagnosis can sometimes be made without cardiac catheterization. Electrocardiography is an electrical tracing of the depolarization of myocardial cells. Cardiac catheterization is an invasive procedure in which a catheter is threaded into the heart, a contrast medium is injected, and the heart and its vessels are visualized. Electrophysiology is an invasive procedure in which catheters with electrodes record the impulses of the heart directly from the conduction system.

In what procedure are high-frequency sound waves directed through a transducer to produce an image of cardiac structures? 1 Electrophysiology 2 Echocardiography 3 Electrocardiography 4 Cardiac catheterization

1. Relief from dyspnea at rest Pulmonary congestion happens because of the reduced distensibility of the lungs. As a result, less oxygen is available and this in turn causes dyspnea, even in the recumbent position. This can be relieved by sitting up; as the diaphragm lowers, the lungs can get more oxygen. The swelling and irritation of the oral mucosa causes a persistent, dry, hacking cough. Gasping and grunting respirations occur in heart failure. Edema of the bronchial mucosa may produce wheezing due to obstruction of airflow. None of these symptoms can be relieved by just changing the position of the infant.

The nurse asks the parent of an infant with pulmonary congestion to help the infant sit up. What is the nurse trying to achieve? 1 Relief from dyspnea at rest 2 Preventing a persistent, dry, hacking cough 3 Relieving gasping and grunting respirations 4 Preventing wheezing due to the obstruction of airflow

4. Drainage greater than 12 mL/hr for more than 3 hours. Chest tube drainage greater than 3 mL/kg/hr for more than 3 consecutive hours may indicate postoperative hemorrhage. Cardiac tamponade can develop rapidly and is life threatening. Drainage volume of 5 to 10 mL/kg in any 1 hour is excessive and must be reported to the primary health care provider. The largest volume of drainage occurs in the first 12 to 24 hours. It is normal to have bright red drainage immediately after surgery that changes to serous drainage with healing.

The nurse is assessing the chest tube drainage of a 20 kg child in the postoperative period after cardiac surgery. Which drainage, if present in the patient, would prompt the nurse to contact the provider immediately? 1 Drainage volume of 80 mL in 1 hour. 2 Serous drainage after 12 hours postsurgery. 3 Bright red drainage immediately after surgery. 4 Drainage greater than 12 mL/hr for more than 3 hours.

1. Echocardiogram Echocardiograms are used to monitor myocardial and coronary artery status. A baseline echocardiogram should be obtained at the time of diagnosis for comparison with future studies. Long-term complications of KD include the development of coronary artery aneurysms and disrupting blood flow. In the convalescent phase, intake, output, and daily weight all return to normal. The convalescent phase is complete when all blood values such as complete blood count and erythrocyte sedimentation rate are normal. This is 6 to 8 weeks after the onset of the disease.

The nurse is caring for a child with Kawasaki disease (KD). Which intervention performed at the time of diagnosis does the nurse refer to for evaluating long-term complications? 1 Echocardiogram 2 Intake and output record 3 Complete blood count 4 Erythrocyte sedimentation rate

4. Ensure that the white electrode is on the right of the chest. Electrodes for cardiac monitoring are often color coded. White electrodes are placed on the right side of the chest, above the level of the heart. The black electrode is placed on the left chest above the level of the heart, not the right leg. Electrodes should be changed every 1 or 2 days because they irritate the skin. Bedside monitors assist in patient care. However, the nurse should assess the patient and not the cardiac monitor for auscultation of heart sounds. The ground electrode is green or red and is placed on the abdomen.

The nurse is caring for a child with a bedside cardiac monitor for electrocardiogram (ECG). Which intervention by the nurse is appropriate? 1. Change electrodes on the patient every 12 hours. 2. Assess the cardiac monitor frequently for heart sounds. 3. Ensure that the black electrode is placed on the right leg. 4. Ensure that the white electrode is on the right of the chest.

2. Medication may be used to sedate the child. The nurse should teach the parents about minimizing the metabolic needs of the child and lessening the workload on the heart. An irritable or crying child has a greater demand for oxygen, which increases cardiac demands. Nurses may use medication to sedate the child. Parents should not play with the child too often, because this increases cardiac demands. The child should be allowed to rest as much as possible, without any external or environmental stimuli. The child should be placed in a semi-Fowler position to reduce the effort of breathing. The child should have a neutral thermal environment to prevent cold stress.

The nurse is caring for a child with heart failure. What teaching does the nurse give to the parents of the child about reducing the workload on the child's heart while hospitalized? 1 Play with the child as often as possible. 2 Medication may be used to sedate the child. 3 Place the child in a supine position at all times. 4 Ensure a cool temperature in the child's room.

3. Organizing activities to permit uninterrupted sleep The child needs to be well-rested before feeding. The child's needs should be met to minimize crying. The nurse must organize care to decrease energy expenditure. The child in congestive heart failure has an excess of fluid, so forcing fluids is contraindicated. Monitoring of vital signs is appropriate, but minimizing energy expenditure is a priority. The child often cannot tolerate larger feedings; small, frequent feedings should be given to the child in congestive heart failure.

The nurse is planning care for an infant with heart failure. Which intervention does the nurse include? 1 Forcing fluids appropriate to age 2 Monitoring respirations during active periods 3 Organizing activities to permit uninterrupted sleep 4 Giving larger feedings less often to conserve energy

2. Refrain from drawing up the dose because there is an error in the dosage. Digoxin is often prescribed in micrograms. Rarely is more than 1 mL administered to an infant. As a potentially dangerous drug, digoxin has precise administration guidelines. Some institutions require that digoxin dosages be checked by another professional before administration. The nurse has drawn up too much medication and should not give it to the child. Administering the dose through a nipple is the correct procedure, but too much medication has been prepared, so it should not be given to the child. Administering the dose by placing it at the back and side of the mouth is the correct procedure, but too much medication has been prepared, so it should not be given to the child.

The nurse, preparing to give digoxin to a 9-month-old infant, checks the dosage and sees that 4 mL of the drug is to be administered. Which action by the nurse is correct? 1 Mix the dose with juice to disguise its taste. 2 Refrain from drawing up the dose because there is an error in the dosage. 3 Check the heart rate and administer the dose by letting the infant suck it through a nipple. 4 Check the heart rate and administer the dose by placing it at the back and side of the mouth.

1. Record output as soon as the drug is given Furosemide is a diuretic used in heart failure. It blocks the reabsorption of sodium and water in the proximal renal tubule. Output should be recorded as soon as the medication is administered, and the child must be monitored for dehydration. Furosemide causes excretion of chloride and potassium. Therefore, the child must be encouraged to have foods high in potassium or given potassium supplements. One of the side effects of furosemide is postural hypotension. Skin rash and drowsiness are side effects seen in children who receive spironolactone.

The patient with heart failure receives furosemide intravenously. Which intervention is appropriate? 1 Record output as soon as the drug is given. 2 Do not give foods high in potassium. 3 Observe for signs of hypertension. 4 Observe for skin rash and drowsiness.

4. Cooler lower extremities An infant with coarctation of the aorta, an obstructive defect of the heart, has cooler lower extremities due to localized narrowing near the insertion of the ductus arteriosus. This leads to decreased pressure in the lower extremities and weak or absent femoral pulses. The narrowing also causes increased pressure in the head and upper extremities and bounding pulses in the arms.

What clinical manifestation does the nurse expect to find during the assessment of an infant with coarctation of the aorta? 1 Bounding femoral pulses 2 Low pressure in the arms 3 Weak pulses in the arms 4 Cooler lower extremities

2. Splinter hemorrhages under the nails Splinter hemorrhages, or thick black lines, under the nails are a manifestation of infective endocarditis caused by extracardiac emboli formation. Swollen, red, hot, and painful joints are observed in a child with polyarthritis. Sudden aimless movement of the extremities and involuntary facial grimaces and tics are clinical manifestations of chorea during the initial attack of rheumatic fever. These may occur in children who have not been diagnosed with rheumatic fever.

What clinical manifestation should the nurse expect to find in a child with infective endocarditis? 1 Swollen, red, hot, and painful joints 2 Splinter hemorrhages under the nails 3 Aimless movement of the extremities 4 Involuntary facial grimaces and tics

4 Keep the child on the same medication schedule. There is a very narrow margin of safety between therapeutic, toxic, and lethal doses of digoxin. The nurse keeps the child on the same medication schedule when a single dose of digoxin is missed. The dose should not be increased. Doubling the dose may cause digoxin toxicity. If more than two consecutive doses have been missed, the primary health care provider must be notified.

What does the nurse do when the digoxin dose of a child is missed? 1 Double the next scheduled dose. 2 Notify the primary health care provider immediately. 3 Give an extra dose as soon as possible. 4 Keep the child on the same medication schedule.

4. The desirability of promoting normalcy within the limits of the child's condition The child needs social interactions, discipline, and appropriate limit-setting. Parents need to be encouraged to promote as normal a life as possible for their child. The child requires increased caloric intake after cardiac surgery. Because cyanotic spells will occur in children with some defects, the parents need to be taught how to identify and manage them appropriately; this will ease their anxiety and concern.

What does the nurse stress when counseling parents regarding the home care of the child with a cardiac defect before corrective surgery? 1 The need to be extremely concerned about cyanotic spells 2 The importance of relaxing discipline and limit-setting to prevent crying 3 The importance of reducing caloric intake to decrease cardiac demands 4 The desirability of promoting normalcy within the limits of the child's condition

1. Institute prophylactic antibiotic therapy The parents must take adequate measures to prevent infection. The child must be administered prophylactic antibiotic therapy 1 hour before certain procedures, such as dental work. Treatment of IE requires long-term parenteral drug therapy. Intravenous antibiotics may be administered at home with nursing supervision. Any unexplained fever, weight loss, lethargy, malaise, or anorexia must be reported to the health care provider. Such symptoms should not be self-diagnosed as a cold or flu, nor should they be treated with over-the-counter drugs. Early diagnosis and treatment are important in preventing further cardiac damage, embolic complications, and growth of resistant organisms. Blood cultures must be taken periodically to evaluate the response to antibiotic therapy.

What does the nurse teach the parents of a child who has a history of bacterial infective endocarditis (IE)? 1 Institute prophylactic antibiotic therapy. 2 Treat with short-term oral drug therapy. 3 Treat a cold with over-the-counter drugs. 4 Take blood culture before dental work.

4. "The child has cyanosis associated with a lack of oxygen." The nurse teaches the parents that the child has a bluish color because of reduced oxygen saturation. This condition, called cyanosis, occurs when blood has deoxygenated hemoglobin at a concentration of 5g/dL or more. Despite a near-normal partial pressure of oxygen, patients with polycythemia have a high concentration of deoxygenated hemoglobin, and may appear cyanotic. In cyanotic children, fluid restriction can cause dehydration and increase the risks of cerebrovascular accidents. The nurse must reassure the parents that the bluish color of the skin or mucous membrane does not imply a lack of oxygen to the brain.

What does the nurse teach the parents who are concerned and fearful of their child's bluish color? 1 "The child has very low partial pressure of oxygen." 2 "The bluish color can be reduced by fluid restriction." 3 "The color change implies a lack of oxygen to the brain." 4 "The child has cyanosis associated with a lack of oxygen."

3. The child will not have distended neck veins. A lack of distended neck veins is an appropriate patient outcome for a child with congestive heart failure. The child should have a heart rate that is acceptable for age rather than rapid. The skin should be warm to touch rather than cool. The child should sleep with the head elevated rather than with the head down and the feet elevated.

What is a priority patient outcome for a child with congestive heart failure? 1. The child will have a rapid heart rate. 2. The child will have skin that is cool to touch. 3. The child will not have distended neck veins. 4. The child will sleep with the head down and feet elevated.

3. Knee-chest The squatting position, otherwise known as the knee-chest position, decreases the amount of blood returning to the heart and allows the child time to compensate. The prone and supine positions do not offer any advantages to the child with cardiac compromise. The low Fowler position would assist with respiratory issues but not with cardiac compensation.

What position does the nurse caring for a young child with tetralogy of Fallot see the child assuming in an attempt to compensate for the congenital heart defect? 1 Prone 2 Supine 3 Knee-chest 4 Low Fowler

2, 3, 4 The nurse must assess the child for signs and symptoms of infection. The procedure may be cancelled in case of severe diaper rash if femoral access is required. A history of allergies is important to obtain, because some of the contrast agents are iodine-based. The nurse must obtain an accurate height measurement of the child to ensure correct catheter selection. Assessment of pedal pulses is important after catheterization. The nurse should therefore assess the presence and quality of pedal pulses before the procedure. The nurse must ensure that the child is NPO for 4 to 6 hours or more before the procedure.

What preprocedural interventions does the nurse implement for a child who is prescribed a cardiac catheterization? Select all that apply. 1 Assess the quality of the apical pulse. 2 Assess for any symptoms of infection. 3 Obtain history for any allergic reactions. 4 Obtain an accurate height measurement of the child. 5 Ensure nothing by mouth (NPO) 3 hours before procedure.

2, 3, 5 Maintenance doses of digoxin (Lanoxin) are given every 12 hours, such as at 8 AM and 8 PM. Digoxin can be dangerous because it has a narrow margin of safety between therapeutic, toxic, and lethal doses. Frequent vomiting, poor feeding, or a slow heart rate can be signs of toxicity. The health care provider must be notified if any of these signs are observed in the child. The child must be given water after administering the drug and encouraged to brush the teeth to prevent tooth decay. The drug must not be mixed with food or fluids, because the child will receive an inaccurate dosage if the child refuses to have the food and other fluids. If the child vomits after a dose, a second dose should not be given, because this may lead to an overdose.

What teaching should the nurse give to the principal caregiver of a child about the administration of digoxin? Select all that apply. 1 Mix the drug with some food or fluids. 2 Administer the drug every 12 hours. 3 Report frequent vomiting or poor feeding. 4 Give a second dose if the child vomits. 5 Give water after administering the drug.

4. Counting the apical rate for 1 full minute and comparing it with the radial rate Counting apical rate for 1 full minute and comparing it with the radial rate is the nurse's first action. If a dysrhythmia is occurring, the radial pulse may be lower than the apical rate. Notifying the catheterization lab is not the first action until a thorough assessment is completed to determine what type of dysrhythmia is present. A complete assessment needs to be conducted before any medications are administered. Radial pulse needs to be compared with apical. It is the nurse's responsibility to check both rates, radial and apical.

When a dysrhythmia is suspected, which is the nurse's first action? 1 Notifying the heart catheterization lab 2 Administering an antidysrhythmic medication 3 Counting the radial pulse every minute for 5 minutes 4 Counting the apical rate for 1 full minute and comparing it with the radial rate

1, 2, 5- cyanosis, tachypnea, costal retractions In an infant with heart failure, cyanosis, tachypnea, and costal retractions occur due to pulmonary congestion. Cyanosis occurs due to impaired gas exchange because oxygen does not reach the alveoli for gas exchange in adequate amounts due to fast breathing rates. The fast breathing, or tachypnea, is in response to the decreased ability of the lungs to expand. During attempts to ventilate the noncompliant lungs, the pliable chest wall of the infant is drawn inward, resulting in costal retractions. Tachycardia and a gallop rhythm are the result of impaired myocardial function rather than pulmonary congestion. Tachycardia is a direct result of sympathetic stimulation of the myocardium. Gallop rhythm refers to the extra heart sounds S 3and S 4that occur due to ventricular dilation and excess preload.

Which clinical manifestations of heart failure in an infant occur due to pulmonary congestion rather than impaired myocardial function? Select all that apply. 1 Cyanosis 2 Tachypnea 3 Tachycardia 4 Gallop rhythm 5 Costal retractions

4. Tachypnea, exercise intolerance, cyanosis Tachypnea, exercise intolerance, and cyanosis, along with orthopnea, wheezing, and cough, are clinical manifestations of pulmonary congestion in children with congestive heart failure. Fatigue and restlessness are the result of impaired myocardial function, and weight gain is caused by systemic venous congestion.

Which clinical manifestations result from pulmonary congestion in children with congestive heart failure? 1 Weight gain, cough, cyanosis 2 Fatigue, tachypnea, orthopnea 3 Restlessness, cyanosis, wheezing 4 Tachypnea, exercise intolerance, cyanosis

4. Atrioventricular canal defect Atrioventricular canal defect is the incomplete fusion of the endocardial cushions. Atrial septal defect is abnormal opening between the atria. Ventricular septal defect is an abnormal opening between right and left ventricles. Patent ductus arteriosus is the failure of the fetal ductus arteriosus to close within the first weeks of life.

Which congenital heart defect is described as the incomplete fusion of the endocardial cushions? 1 Atrial septal defect 2 Ventricular septal defect 3 Patent ductus arteriosus 4 Atrioventricular canal defect

1. Aortic stenosis Aortic stenosis causes narrowing of the aortic valve, which in turn results in resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. Atrial septal defect is an abnormal opening between the atria that allows blood from the higher-pressure left atrium to flow into the lower-pressure right atrium. Coarctation of the aorta is an obstructive defect in which there is narrowing near the insertion of the ductus arteriosus. Patent ductus arteriosus is the failure of the fetal ductus arteriosus to close during the first few weeks of life.

Which heart defect causes narrowing of the aortic valve? 1 Aortic stenosis 2 Atrial septal defect 3 Coarctation of the aorta 4 Patent ductus arteriosus

1. Quiet the child when the blood pressure is recorded The nurse must quiet the child to obtain an accurate blood pressure reading and to avoid false readings caused by excitement. Initial evaluation of the child should include pressure at the four extremities, with the child in the supine position, to rule out coarctation of the aorta. Falsely elevated blood pressure readings can be avoided by using properly fitted cuffs. Blood pressure should be measured with the arm at the level of the heart for accuracy.

Which intervention should the nurse take when obtaining a blood pressure measurement for a child with systemic hypertension? 1 Quiet the child when the blood pressure is recorded. 2 Note pressure at the four extremities in a sitting position. 3 Measure blood pressure with narrow-fitting cuffs. 4 Measure blood pressure with the arm above the heart level.

1. Tachypnea Tachypnea is one of the early signs of congestive heart failure that should be identified. Tachycardia at rest, dyspnea, retractions, and activity intolerance are other physical signs and symptoms. Tachycardia, not bradycardia, is one of the symptoms suggestive of congestive heart failure. The child with congestive heart failure may be diaphoretic and exhibit decreased urine output.

Which is an early sign of congestive heart failure? 1 Tachypnea 2 Bradycardia 3 Inability to sweat 4 Increased urine output

4. Transposition of the great arteries Transposition of the great arteries permits mixing of oxygenated and unoxygenated blood in the heart. Pulmonic stenosis is classified as an obstructive defect. Atrial septal defect is classified as a defect with increased pulmonary blood flow. Patent ductus arteriosus is classified as a defect with increased pulmonary blood flow.

Which is considered a mixed cardiac defect? 1 Pulmonic stenosis 2 Atrial septal defect 3 Patent ductus arteriosus 4 Transposition of the great arteries

3. Checking the pulses distal to the catheterization site Monitoring the pulses distal to the catheterization site helps reduce the chance of perfusion problems after cardiac catheterization. Resuming a regular diet, using acetaminophen or ibuprofen for pain, and monitoring the site for redness, swelling, drainage, bleeding, temperature, and color are appropriate nursing interventions but will not reduce the chance of perfusion problems after cardiac catheterization.

Which is the priority nursing intervention for reducing the risk for perfusion problems after cardiac catheterization? 1 Resuming the regular diet without restrictions 2 Using acetaminophen or ibuprofen to relieve pain 3 Checking the pulses distal to the catheterization site 4 Monitoring the site for redness, swelling, drainage, bleeding, temperature, and color Monitoring the pulses distal to the catheterization site helps reduce the chance of perfusion problems after cardiac catheterization. Resuming a regular diet, using acetaminophen or ibuprofen for pain, and monitoring the site for redness, swelling, drainage, bleeding, temperature, and color are appropriate nursing interventions but will not reduce the chance of perfusion problems after cardiac catheterization.

3. Checking the apical pulse for 60 seconds before administering the medication The child's apical pulse should be assessed for 60 seconds before the medication is administered; the medication should be held if the apical pulse is below 90 to 110 beats per minute in infants and young children or below 70 beats per minute in older children. Assessing the blood pressure or the carotid pulse before giving digoxin is not necessary.

Which nursing intervention is the most important in preventing complications of digoxin administration? 1 Assessing blood pressure in all extremities 2 Assessing blood pressure with the patient lying, sitting, and standing 3 Checking the apical pulse for 60 seconds before administering the medication 4 Checking the carotid pulse for 30 seconds before administering the medication

1, 3 Kawasaki disease (KD) is an acute systemic vasculitis. It is important to monitor the child's temperature carefully because fever reflects ongoing inflammation, which may indicate the need for further treatment. Intravenous immunoglobulin (IVIG) is administered to improve ventricular function. The nurse should check the patency of the intravenous line, because extravasation can result in tissue damage. If the child develops arthritis, passive range-of-motion exercises may be advised. If the body temperature is very high, acetaminophen is given along with high doses of aspirin. Although children with KD may be partially dehydrated, fluids need to be administered with utmost care due to the usual finding of myocarditis.

Which nursing interventions are most important when the nurse is managing the care for a child with Kawasaki disease? Select all that apply. 1 Monitor temperature carefully. 2 Encourage the child to do active exercises. 3 Check the patency of the intravenous line. 4 Administer acetaminophen to relieve pain. 5 Ensure rehydration through periodic fluid intake.

3. Ensure the child is warm immediately after surgery. Hypothermia is expected immediately after surgery from hypothermia procedures, effects of anesthesia, and loss of body heat to the cool environment. The operating room is kept fairly cold, and this adds to the hypothermia. During this period, the child is kept warm to prevent additional heat loss. Heart rate and respirations are counted for 1 full minute, compared with the electrocardiogram monitor, and recorded with activity. The heart rate is normally increased after surgery. The lungs are auscultated for breath sounds hourly. Diminished or absent sounds need further assessment. Fluids are restricted during the immediate postoperative period. This is done to prevent hypervolemia, which places additional demands on the myocardium, predisposing the child to cardiac failure.

Which postoperative care does the nurse include for a child immediately after surgery? 1 Count the heart rate and respirations for 30 seconds. 2 Auscultate the lungs bilaterally once every 2 hours. 3 Ensure the child is warm immediately after surgery. 4 Provide fluids in the immediate postoperative period.